Cough, nonproductive: Excerpt from Nursing: Interpreting

Signs and Symptoms

A nonproductive cough is a noisy, forceful expulsion of air from the lungs that doesn't yield
sputum or blood. It's one of the most common complaints of patients with respiratory disorders.

Coughing is a necessary protective mechanism that clears airway passages. However, a

nonproductive cough is ineffective and can cause damage, such as airway collapse or rupture of
alveoli or blebs. A nonproductive cough that later becomes productive is a classic sign of
progressive respiratory disease.

The cough reflex generally occurs when mechanical, chemical, thermal, inflammatory, or
psychogenic stimuli activate cough receptors. (See Reviewing the cough mechanism, page 156.)

However, external pressure—for example, from subdiaphragmatic irritation or a mediastinal

tumor—can also induce it, as well as voluntary expiration of air, which occasionally occurs as a
nervous habit. Certain drugs, such as angiotensin-converting enzyme inhibitors, may also cause a
nonproductive cough.

A nonproductive cough may occur in paroxysms and can worsen by becoming more frequent.
An acute cough has a sudden onset and may be self-limiting; a cough that persists beyond 1
month is considered chronic and commonly results from cigarette smoking.

Someone with a chronic nonproductive cough may downplay or overlook it or accept it as

normal. In fact, he generally won't seek medical attention unless he has other symptoms. A
foreign body in a child's external auditory canal may result in a cough. Always examine the
child's ears.

History and physical examination

Ask the patient when his cough began and whether body position, the time of day, or a specific
activity affects it. How does the cough sound—harsh, brassy, dry, or hacking? Try to determine
if the cough is related to smoking or a chemical irritant. If the patient smokes or has smoked,
note the number of packs smoked daily multiplied by years (“pack-years”). Next, ask about the
frequency and intensity of the coughing. If he has pain associated with coughing, breathing, or
activity, when did it begin? Where is it located?

Ask the patient about recent illness (especially a cardiovascular or pulmonary disorder), surgery,
or trauma. Also ask about hypersensitivity to drugs, foods, pets, dust, or pollen. Find out which
medications the patient takes, if any, and ask about recent changes in schedule or dosages. Ask
about recent changes in his appetite, weight, exercise tolerance, or energy level and recent
exposure to irritating fumes, chemicals, or smoke.
As you're taking his history, observe the patient's general appearance and manner: Is he agitated,
restless, or lethargic; pale, diaphoretic, or flushed; anxious, confused, or nervous? Also, note
whether he's cyanotic or has clubbed fingers or peripheral edema.

Next, perform a physical examination. Start by taking the patient's vital signs. Check the depth
and rhythm of his respirations, and note if wheezing or “crowing” noises occur with breathing.
Feel the patient's skin: Is it cold or warm; clammy or dry? Check his nose and mouth for
congestion, inflammation, drainage, or signs of infection. Inspect his neck for distended jugular
veins and tracheal deviation, and palpate for masses or enlarged lymph nodes.

Examine his chest, observing its configuration and looking for abnormal chest wall motion. Do
you note any retractions or use of accessory muscles? Percuss for dullness, tympany, or flatness.
Auscultate for wheezing, crackles, rhonchi, pleural friction rubs, and decreased or absent breath
sounds. Finally, examine his abdomen for distention, tenderness, masses, or abnormal bowel
sounds.

Medical causes
Airway occlusion.Partial occlusion of the upper airway produces a sudden onset of dry,
paroxysmal coughing. The patient is gagging, wheezing, and hoarse, with stridor, tachycardia,
and decreased breath sounds.

Anthrax (inhalation).Inhalation anthrax is caused by inhaling aerosolized spores. Initial signs

and symptoms are flulike and include a fever, chills, weakness, a cough, and chest pain. The
disease generally occurs in two stages, with a period of recovery after the initial signs and
symptoms. The second stage develops abruptly with rapid deterioration marked by a fever,
dyspnea, stridor, and hypotension generally leading to death within 24 hours. Radiologic
findings include mediastinitis and symmetric mediastinal widening.

Aortic aneurysm (thoracic).Aortic aneurysm causes a brassy cough with dyspnea, hoarseness,
wheezing, and a substernal ache in the shoulders, lower back, or abdomen. The patient may also
have facial or neck edema, jugular vein distention, dysphagia, prominent veins over his chest,
stridor and, possibly, paresthesia or neuralgia.

Asthma.Asthma attacks typically occur at night, starting with a nonproductive cough and mild
wheezing; this progresses to severe dyspnea, audible wheezing, chest tightness, and a cough that
produces thick mucus. Other signs include apprehension, rhonchi, prolonged expirations,
intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils,
tachypnea, tachycardia, diaphoresis, and flushing or cyanosis.

Atelectasis.As lung tissue deflates, it stimulates cough receptors, causing a nonproductive

cough. The patient may also have pleuritic chest pain, anxiety, dyspnea, tachypnea, and
tachycardia. His skin may be cyanotic and diaphoretic, his breath sounds may be decreased, his
chest may be dull on percussion, and he may exhibit inspiratory lag, substernal or intercostal
retractions, decreased vocal fremitus, and tracheal deviation toward the affected side.
Avian influenza.Individuals infected with avian influenza may initially have symptoms of
conventional influenza, including a nonproductive cough, fever, sore throat, and muscle aches.
The most virulent avian virus, influenza A (H5N1), may lead to severe and life-threatening
complications, such as acute respiratory distress and pneumonia.

Bronchitis (chronic).Bronchitis starts with a nonproductive, hacking cough that later becomes
productive. Other findings include prolonged expiration, wheezing, dyspnea, accessory muscle
use, barrel chest, cyanosis, tachypnea, crackles, and scattered rhonchi. Clubbing can occur in late
stages.

Bronchogenic carcinoma.The earliest indicators of bronchogenic carcinoma can be a chronic,

nonproductive cough; dyspnea; and vague chest pain. The patient may also be wheezing.

Common cold.The common cold generally starts with a nonproductive, hacking cough and
progresses to some mix of sneezing, headaches, malaise, fatigue, rhinorrhea, myalgia, arthralgia,
nasal congestion, and a sore throat.

Esophageal achalasia.In esophageal achalasia, regurgitation and aspiration produce a dry

cough. The patient may also have recurrent pulmonary infections and dysphagia.

Esophageal diverticula.The patient with esophageal diverticula has a nocturnal nonproductive

cough, regurgitation and aspiration, dyspepsia, and dysphagia. His neck may appear swollen and
have a gurgling sound. He may also exhibit halitosis and weight loss.

Esophageal occlusion.Esophageal occlusion is marked by immediate nonproductive coughing

and gagging, with a sensation of something stuck in the throat. Other findings include neck or
chest pain, dysphagia, and the inability to swallow.

Hantavirus pulmonary syndrome.A nonproductive cough is common in patients with

Hantavirus pulmonary syndrome, which is marked by noncardiogenic pulmonary edema. Other
findings include a headache, myalgia, fever, nausea, and vomiting.

Hypersensitivity pneumonitis.With hypersensitivity pneumonitis, an acute nonproductive

cough, a fever, dyspnea, and malaise usually occur 5 or 6 hours after exposure to an antigen.

Interstitial lung disease.A patient with interstitial lung disease has a nonproductive cough and
progressive dyspnea. He may also be cyanotic and have clubbing, fine crackles, fatigue, variable
chest pain, and weight loss.

Laryngeal tumor.A mild, nonproductive cough is an early sign of a laryngeal tumor, in addition
to minor throat discomfort and hoarseness. Later, dysphagia, dyspnea, cervical
lymphadenopathy, stridor, and an earache may occur.

Laryngitis.In its acute form, laryngitis causes a nonproductive cough with localized pain
(especially when the patient is swallowing or speaking) as well as fever and malaise. His
hoarseness can range from mild to complete loss of voice.
Lung abscess.Lung abscess typically begins with a nonproductive cough, weakness, dyspnea,
and pleuritic chest pain. The patient may also exhibit diaphoresis, a fever, a headache, malaise,
fatigue, crackles, decreased breath sounds, anorexia, and weight loss. Later, his cough produces
large amounts of purulent, foul-smelling and, possibly, bloody sputum.

Pleural effusion.A nonproductive cough along with dyspnea, pleuritic chest pain, and decreased
chest motion are characteristic of pleural effusion. Other findings include a pleural friction rub,
tachycardia, tachypnea, egophony, flatness on percussion, decreased or absent breath sounds, and
decreased tactile fremitus.

Pneumonia.Bacterial pneumonia usually starts with a nonproductive, hacking, painful cough

that rapidly becomes productive. Other findings include shaking chills, a headache, a high fever,
dyspnea, pleuritic chest pain, tachypnea, tachycardia, grunting respirations, nasal flaring,
decreased breath sounds, fine crackles, rhonchi, and cyanosis. The patient's chest may be dull on
percussion.

With mycoplasma pneumonia, a nonproductive cough arises 2 or 3 days after the onset of
malaise, a headache, and a sore throat. The cough can be paroxysmal, causing substernal chest
pain. Fever commonly occurs, but the patient doesn't appear seriously ill.

Viral pneumonia causes a nonproductive, hacking cough and the gradual onset of malaise,
headache, anorexia, and a low-grade fever.

Pneumothorax.Pneumothorax is a life-threatening disorder that causes a dry cough and signs of

respiratory distress, such as severe dyspnea, tachycardia, tachypnea, and cyanosis. The patient
experiences sudden, sharp chest pain that worsens with chest movement as well as subcutaneous
crepitation, hyperresonance or tympany, decreased vocal fremitus, and decreased or absent
breath sounds on the affected side.

Pulmonary edema.Pulmonary edema initially causes a dry cough, exertional dyspnea,

paroxysmal nocturnal dyspnea, orthopnea, tachycardia, tachypnea, dependent crackles, a
ventricular gallop, and anxiety and restlessness. If pulmonary edema is severe, the patient's
respirations become more rapid and labored, with diffuse crackles and coughing that produces
frothy, bloody sputum.

Pulmonary embolism.A life-threatening pulmonary embolism may suddenly produce a dry

cough along with dyspnea and pleuritic or anginal chest pain. Typically, however, the cough
produces blood-tinged sputum. Tachycardia and a low-grade fever are also common; less
common signs and symptoms include massive hemoptysis, chest splinting, leg edema and, with a
large embolus, cyanosis, syncope, and jugular vein distention. The patient may also have a
pleural friction rub, diffuse wheezing, dullness on percussion, and decreased breath sounds.

Sarcoidosis.With sarcoidosis, a nonproductive cough is accompanied by dyspnea, substernal

pain, and malaise. The patient may also develop fatigue, arthralgia, myalgia, weight loss,
tachypnea, crackles, lymphadenopathy, hepatosplenomegaly, skin lesions, visual impairment,
difficulty swallowing, and arrhythmias.
Severe acute respiratory syndrome (SARS).SARS generally begins with a fever (usually
greater than 100.4° F [38° C]). Other symptoms include a headache; malaise; a dry,
nonproductive cough; and dyspnea. The severity of the illness is highly variable, ranging from
mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.

Tracheobronchitis (acute).Initially, tracheobronchitis produces a dry cough that later becomes

productive as secretions increase. Chills, a sore throat, a slight fever, muscle and back pain, and
substernal tightness generally precede the cough's onset. Rhonchi and wheezes are usually heard.
Severe illness causes a fever of 101° to 102° F (38.3° to 38.9° C) and, possibly, bronchospasm,
with severe wheezing and increased coughing.

Tularemia.Signs and symptoms of tularemia following inhalation of the organism include the
abrupt onset of a fever, chills, a headache, generalized myalgia, a nonproductive cough, dyspnea,
pleuritic chest pain, and empyema.

Other causes
Diagnostic tests.Pulmonary function tests (PFTs) and bronchoscopy may stimulate cough
receptors and trigger coughing.

Treatments.Irritation of the carina during suctioning or deep endotracheal or tracheal tube

placement can trigger a paroxysmal or hacking cough. Intermittent positive-pressure breathing or
spirometry can also cause a nonproductive cough. Some inhalants, such as pentamidine, may
stimulate coughing.

Nursing considerations
▪ A nonproductive, paroxysmal cough may induce life-threatening bronchospasm; the patient
may need a bronchodilator to relieve his bronchospasm and open his airways.

▪ Unless he has chronic obstructive pulmonary disease, you may have to give the patient an
antitussive and a sedative to suppress the cough.

▪ To relieve mucous membrane inflammation and dryness, humidify the air in the patient's room.

▪ Prepare the patient for diagnostic tests, such as X-rays, a lung scan, bronchoscopy, and PFTs.

Patient teaching
▪ Teach the patient to use a humidifier if his home is dry.

▪ Tell him to avoid using aerosols, powders, or other respiratory irritants—especially cigarettes.

▪ If the patient smokes, stress the importance of smoking cessation, and refer him to appropriate
resources, support groups, and information to help him quit smoking.
▪ Explain the importance of adequate fluids and nutrition.

▪ Explain to the patient the cause of his cough and the treatment plan.

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